It has become increasingly common for business entities to exchange data in electronic form. The use of e-mail and the Internet to communicate has allowed commerce to proceed at a much faster pace and for cost savings to be realized from the speed involved and the smaller number of people needed to pass communications. Specialized data communication between trading partners, such as a manufacturing company and its suppliers, typically requires the set up and maintenance of a distinct and proprietary data exchange system. Setting up these proprietary systems has enabled cost savings to be realized, but requires each pair of trading partners to spend time programming, testing, debugging and converting data in their systems at each end. The debugging process may be further complicated as occurrence of an error may require systems to be modified on each end. Where an entity has a number of trading partners, such as a distributor receiving orders from a number of retailers, this process has to be repeated for each trading partner added to the system.
There have been attempts to standardize the interchange of electronic data, such as the American National Standards Institute (ANSI) Accredited Standards Committee (ASC) X12 that develops uniform standards for electronic interchange of business transactions—electronic data interchange (EDI). While the adoption of common standards has simplified the process of selecting and implementing EDI systems, the testing and debugging process still requires the large investment of time and effort on each side.
While some health care providers currently use EDI transactions to achieve cost savings in transactions, there is no currently implemented standard format. Currently, about 400 different EDI formats are being used in the health care area. The Health Insurance Portability and Accountability Act (HIPAA), enacted in 1996, requires U.S.-based health care providers, clearinghouses, claims processors and payers to transmit claims and other health care transactions using a set of common EDI standards. These national standards were proposed in Federal Register Vol. 63, No. 88, page 25272, et seq., Health Insurance Reform: Standards for Electronic Transactions and adopted in 45 CFR Parts 160 and 162, as published in the Federal Register Vol. 65, No. 160, pages 50312 to 50372, Health Insurance Reform: Standards for Electronic Transactions, each of which is incorporated in its entirety herein. Addenda and clarifications to these rules are produced by the process contained in Federal Register Vol. 65, No. 160, page 50373, Health Insurance Reform Announcement of Designated Maintenance Standards Organizations and Federal Register, Vol. 65, No. 227, each of which is incorporated by reference in its entirety herein. A number of X12 Implementation guides have been developed and are available from the ASC X12 committee, setting and detailing the specific standards for the different aspects of the health care industry and the implementation of their adoption by all health care providers. Some of these implementation guidelines have been adopted by the Secretary of Health and Human Services as HIPAA Standard transactions, while other guides are for voluntary adoption by the healthcare industry and may be adopted by the Secretary of HHS at a later time. These implementation guides include National Electronic Data Interchange Transaction Set Implementation Guide, Health Care Claim Request for Additional Information 277; National Electronic Data Interchange Transaction Set Implementation Guide, Health Care Data Element Dictionary, May 2000; Logical Observation Identifier Names and Codes (LOINC®) Committee, LOINC® Modifier Codes For Use With ASC X12N 277 Implementation Guides when Requesting Additional Information, NPRM Draft Dec. 10, 2001; National Electronic Data Interchange Transaction Set Implementation Guide, Payroll Deducted and Other Group Premium Payment for Insurance Products 820, ASC X12N 820 (004010X061), May 2000; National Electronic Data Interchange Transaction Set Implementation Guide, Payroll Deducted and Other Group Premium Payment For Insurance Products 820 ADDENDA, ASC X12N 820 (004010X061A1); National Electronic Data Interchange Transaction Set Implementation Guide, Health Care Claim Payment/Advice 835, ASC X12N 835 (004010X091), May 2000; National Electronic Data Interchange Transaction Set Implementation Guide, Health Care Claim Payment/Advice 835 ADDENDA, ASC X12N 835 (004010X091A1); National Electronic Data Interchange Transaction Set Implementation Guide, Health Care Eligibility Benefit Inquiry and Response 270/271, ASC X12N 270/271 (004010X092), May 2000; National Electronic Data Interchange Transaction Set Implementation Guide, Health Care Eligibility Benefit Inquiry and Response 270/271 ADDENDA, ASC X12N 270/271 (004010X092A1), October 2001 NPRM Draft; National Electronic Data Interchange Transaction Set Implementation Guide, Health Care Claim Status Request and Response 276/277, ASC X12N 276/277 (004010X093); National Electronic Data Interchange Transaction Set Implementation Guide, Health Care Claim Status Request and Response 276/277 ADDENDA, ASC X12N 276/277 (004010X093A1); National Electronic Data Interchange Transaction Set Implementation Guide, Health Care Services Review—Request for Review and Response 278 ASC X12N 278 (004010X094), May 2000; National Electronic Data Interchange Transaction Set Implementation Guide, Health Care Services Review—Request for Review and Response 278 ADDENDA, ASC X12N 278 (004010X094A1); National Electronic Data Interchange Transaction Set Implementation Guide, Benefit Enrollment and Maintenance 834, ASC X12N 834 (004010X095), May 2000; National Electronic Data Interchange Transaction Set Implementation Guide, Benefit Enrollment and Maintenance 834 ADDENDA, ASC X12N 834 (004010X095A1); National Electronic Data Interchange Transaction Set Implementation Guide, Health Care Claim: Institutional, 837, ASC X12N 837 (004010X096), May 2000; National Electronic Data Interchange Transaction Set Implementation Guide, Health Care Claim: Institutional, 837 ADDENDA, ASC X12N 837 (004010X096A1); National Electronic Data Interchange Transaction Set Implementation Guide, Health Care Claim: Dental, 837 ASC X12N 837 (004010X097), May 2000; National Electronic Data Interchange Transaction Set Implementation Guide, Health Care Claim: Dental, 837 ADDENDA, ASC X12N 837 (004010X097A1); National Electronic Data Interchange Transaction Set Implementation Guide, Health Care Claim: Professional, 837 ASC X12N 837 (004010X098), May 2000; National Electronic Data Interchange Transaction Set Implementation Guide, Health Care Claim: Professional, 837 ADDENDA, ASC X12N 837 (004010X098A1); NCPDP Telecommunication Standard Format, Version 5.1 and the NCPDP Batch Standard, Version 1 Release 0; each of which is incorporated herein by reference in its entirety.
It is estimated that once the standards are adopted, the costs of processing each transaction will drop from $5 to $15 per paper or telephone transaction to $0.85 to $1.25 per standardized EDI transaction. Adoption of similar standards in other fields should have the same effect.
The traditional method of setting up an EDI transaction system is to set a pair of “trading partners” up and convey test messages back and forth between partners, troubleshooting at each end until the system successfully works. Personnel are required at each end and disputes as to which system is the cause of errors are common. This process must be repeated for each pair of trading partners and for each type of transaction to be exchanged. Where there are multiple trading partners, changes made to a system in response to problems with one trading partner may result in problems occurring in transactions with other trading partners. With the sheer numbers of computer systems involved in the medical field, this task may prove almost insurmountable by the October 2003 HIPAA deadline.
There has been software available that is capable of analyzing data files for proper syntax and formatting for ASC X12 or other EDI standards, such as the EDIFECS software, or the EDISIM analyzer software program from Foresight Corporation. Generally, this software has been limited to format checking and conformance to the X12 syntax, and merely serves as an initial tool in the troubleshooting process. The contents of transmissions are not analyzed for business sensibility of the data in the transactions or for proper relationships between different transactions. A file with the proper format that makes no business sense is essentially worthless. System and methods able to analyze the contents of a transmission, including the business contents, and provide independent troubleshooting of the data stream for EDI trading partners would be advantageous.